Archive for the tag 'v11'

The field of Nursing Informatics is still relatively new and not widely understood by many outside of the Healthcare IT industry. Nursing Informatics merges nursing (clinical knowledge) with a technical background. This results in a highly skilled, highly marketable provider liaison who can clearly communicate with physicians and mid-level providers during and after an EHR implementation in a way that is efficient and meaningful.

Nurse Informaticists can have varying levels of nursing experience. They can be home grown, graduates of certificate programs or have advanced degrees in Nursing Informatics. The typical areas of study for an informatics nurse holding an advanced degree includes courses in Database Management, Nursing Research, Health Systems & Policy, Information Systems Life-cycle and Senior Practicum. These courses are all relevant to the Healthcare IT industry and carry real world application and value.

As a Nurse Informaticist for the past 8 years, my services have been most valued by providers who were frustrated post EHR implementation because of added workload, resulting in an extension of their already long work day. My challenge overall has been, and will always be, to keep providers and clinical staff at the center of my work so that patient’s can be the center of theirs. In looking at this from the traditional IT perspective, it may mean building an EHR system that gets the job done. From the Nursing Informatics perspective it means building an EHR system that providers will use to get their job done. In a nutshell, my job is to take care of clinicians so that they can provide satisfactory, high level patient care without a dramatic extension of their work day.

In the market today Nurse Informaticists are hard to come by. However, there seems to be no shortage of job openings for nurses with this type of background. As the field continues to emerge, more and more healthcare organizations will see the value in having a Nurse Informaticist either on staff or in a consultant role.

In this article, I wanted to show you two possible outcomes when working in your v11 Note. You will notice that there are two similar workflows to add and commit clinical data in the note that will impact how a Finish Note task appears in a user’s task list.

While you will find that these two workflows are scaled down to be very basic and generic, I wanted to limit them to clearly demonstrate the difference between the two.

Workflow #1: Committing data while saving and closing the v11 note

In this workflow, we assume that the user already has the patient in context at the clinical desktop.

The basic steps of this workflow are as follows:

Create a new v11 note

Add a new clinical item

For example: add vitals to the patient chart

Select “Save and Close” in the Note window

Select “Save and Continue” on the Encounter Summary

Navigate to the Task List and select the Current Patient – All task view

Here you can see that the outcome is:

– One Active Finish Note task

So in this case, using the Current Patient – All or Current Patient – Active task views, you will see that just one Finish Note task has been created in an active status. The task indicates that the note has been created and saved. Keep in mind, at this point, that the commit action occurred while the user selected Save and Close in the Note. In this workflow, the system only reviewed the data once.

Workflow #2:Committing data prior to saving and closing the v11 note

As we did in the first workflow, here we assume that the user already has the patient in context at the clinical desktop.

The basic steps of this workflow are as follows:

Create a new v11 note

Add a new clinical item

For example: add vitals to the patient chart

Click the Commit button

Select “Save and Continue” on the Encounter Summary

Select “Save and Close” in the Note window

Navigate to the Task List and select the Current Patient – All task view

Here you can see that the outcome is:

– A Complete Finish Note task and an Active Sign-Note task

If you use a task view that simply shows Current Patient – Active, you would not typically see the Finish Note task in this instance, but instead the Sign-Note task. This means the note has not been signed and might not be the task you expect to receive if you seek the Finish Note task.

While a Finish Note task has been generated and marked as Complete, there may yet be information to add to the note. The logic behind this workflow is that the second action of “Save and Close” is the second review after having hit “Commit”, and therefore results in the outcome we see here. In this case, the system has reviewed the data twice, and the Finish Note task in regards to this note is completed and the active Sign Note task is automatically generated.

My advice in this situation is to follow Workflow #1 when working in a v11 Note. If users are creating a note and adding clinical data, but need a provider or second user to receive a Finish Note task and add additional items to the note; use the first workflow. This way, the Finish Note task will be assigned and visible to the correct person, and users will be trained in such a way that ensures the success of this workflow.

With the release of version 11.2, Allscripts Enterprise EHRTM has the ability to define acceptable ranges for vital sign readings based on age and gender. Once this range is defined, when a vital sign is input and falls outside the defined range, users are alerted that this value is an abnormal result. The alert is shown as a red beaker, displayed next to the value in either the Health Maintenance Plan (HMP) or as bolded, red text in the Note Authoring Workspace (NAW).

While four vital signs (Systolic Pressure, Diastolic Pressure, Heart Rate, and Respiration Rate) are pre-delivered with ranges, clients can create their own ranges for any other vital sign, such as Weight. These ranges are defined solely using the SSMT tool using the RID – Reference Range content category. This means that clients do not define these ranges anywhere inside the EnterpriseTM application, instead, are only able to be defined using SSMT.

Tip: The four pre-delivered vital signs will need additional values populated as the user configures the reference ranges.

First and foremost, the organization needs to ascertain what the actual ranges will be. The NIH Clinical Center provides their guidelines of vital sign ranges. One example of guidelines they provide is Pediatric resting values. The organization should be aware of the resources should determine which guidelines to follow, whether it is the American Heart Association or NIH Clinical Center.

Once the decision has been made for which data will drive the decision to move forward and be used by the organization’s EHR, the System Administrator can begin to use those decisions to load the data to the system.

Now let us explore the basic fundamental steps to set up the Vital Sign Reference Ranges.

Ensure the Resultable Item information is reflected in the spreadsheet as it is in the RID

Keep in mind that columns [F] through [K] must be populated with unique values, that are not 0. [F] must be the lowest acceptable normal value, while [K] must be the highest. The numbers in between CANNOT be the same value!

Set [P] to a value of Y when creating new values

Try loading one line to begin – to ensure set up is correct.

It is important to note that this enhancement has no direct effect on Meaningful Use Core Measure 8 – Record Vital Signs. The Record Vital Signs Objective states: “Record and chart changes in the following vital signs: (A) Height (B) Weight (C) Blood pressure (D) Calculate and display body mass index (BMI) (E) Plot and display growth charts for children 2-20 years, including BMI”. The measure being “for more than 50 percent of all unique patients age 2 and over seen by the Eligible Professional, height, weight, and blood pressure are recorded as structured data”. In reviewing the measure documentation, there was no mention of measuring whether or not the vitals being recorded are being flagged as abnormal.

Allscripts Enterprise EHRTM version 11.2 offers a plethora of excellent features and this functionality certainly allows users to optimize the system and how charts are viewed. The return from defining these ranges is to provide the visual indicator that certain recorded vitals are abnormal for the patient in context. So, while there may no added benefit from a Meaningful Use standpoint, there is certainly clinical benefit to utilizing this functionality.

This week, the world lost one of the most innovative people of our time. Steve Jobs, co-founder of Apple Computer, passed away leaving behind quite the legacy. I feel obligated to honor Steve Jobs this week and reflect on how he affected technology in health care.

It is amazing to reflect upon the history of Apple computers. It seems not too long ago, I was learning how to use a Macintosh computer playing Number Crunchers and Oregon Trail in Elementary school. Back then, the idea of a computer with a mouse was relatively new technology! Twenty years later, Jobs’ vision has evolved technology well beyond that grey box, keyboard, and mouse.

Take this timeline for example:

May 1984 – Macintosh was released using a graphical user interface controlled by a mouse (courtesy of Xerox technology)

April 2010 – Apple releases the first iPhone, optimizing a user interface that would pave the way to the iPad and an extensive library of applications that remains the most popular OS to developers today.

What an advancement in technology in twenty six years! So while the only Apple product I own is an iPod, I remain deeply amazed at the technology Apple offers and how much its technology touches our lives. Apple products remains as probably the most popular choice for mobile computing in the United States.

Business Insider published an article in July 2010 titled “10 Ways The iPad is Changing Healthcare”. While it’s a quick click through the list, you certainly get a feel for the opportunities the iPad has presented to healthcare. Examples included “Going Green”, cost savings, and information consolidation. All this was made possible with the vision of Steve Jobs.

Did you know?:

According to Wikipedia on Steve Jobs: “Jobs is listed as either primary inventor or co-inventor in 338 US patents or patent applications related to a range of technologies from actual computer and portable devices to user interfaces (including touch-based), speakers, keyboards, power adapters, staircases, clasps, sleeves, lanyards and packages.”

Being in the Electronic Healthcare Record industry, I want to share a couple examples that resulted from Jobs’ technology.

Thank you to the iOS software and the work by developers at AllscriptsTM, there are two applications that AllscriptsTM offers that can be utilized using an iPad or iPhone.

This is another excellent application that is utilized by healthcare facilities using the iOS software that allows providers to remotely control their AllscriptsTM Electronic Health record from any location.

Features:

Provides real-time access to patient summary information

Includes ePrescribing to the patient’s pharmacy

Integration with Charge capturing and attaching diagnosis codes to scripts

The system is upgraded to Allscripts Enterprise EHRTM (AE-EHR) version 11.2.x- now what to do? Evaluation of current workflows and deciding on the Meaningful Use measures the organization will be using are the next steps. This article will cover some basic key concepts of Meaningful Use as it related to the application and processes as well as examples to provide the foundation to move forward and build. Ideally, obtaining a baseline of the workflows currently used today in each site/clinic prior to the upgrade itself is the recommended approach. This article will highlight at the end the recommended timeline and priority items to provide the best success of not only the upgrade but more importantly capturing meaningful use.

Step 1- Evaluate current state workflows of each site and the role of the end user population

Even if the site recently went Live or had training- end users continuously find new ways to use the application. AE-EHR version 11 in general provides multiple ways to enter information and despite the best training and/or trainer, an end user may change their behavior over time. Not only will a potential different workflow result in inaccurate testing of what is believed in the workflow; it may potentially allow for an area of missed training when moving to version 11.2. Here’s a great example, suppose clinical staff were not trained to enter problems, however over time the providers and office managers of a site have asked clinical staff to enter the problems for physicians. This would have an impact on training for meaningful use. Or, perhaps the staff is trained to enter smoking status on the social history but behavior has recently changed by the end users and they started capturing it in the comments field in vitals because the end user thought it would be quicker.

The best approach is to go to each site and evaluate each role on what they currently do in the application, as well as how they document in the application. This will allow the testing team to accurately test the role based workflows as well as train as appropriate on workflows. Once the current workflow is established then the foundation for configuration and re-training can begin.

Step 2- Decide which of the Meaningful Use Measures will be used by the organization.

The 15 Core measures will be required by all eligible providers, however only 5 of the 10 menu sets are required. Additionally, of the 44 Clinical Quality Measures, three of the Core or Alternate Core will need to be used and three of the remaining Clinical Measures will need to be decided upon in order to have a total of six Clinical Quality Measures.

This step can be quite a task depending on your organization. Here are some sample questions to ask:

Who will be the lead decision maker?

What teams need to be informed of the Meaningful Use objectives- Business Admin, Executive, Physician Core team?

Are there multiple teams that will make decisions on different aspects (clinical versus business versus administrative)?

Do those key decision makers know about Meaningful Use and if so at what level – high-level or detailed?

Will basic ARRA- Meaningful Use training be required?

How will government incentives be paid out (to the organization, to the physician, to the site)? This will be asked at meetings and better to be prepared when instituting workflow change.

What providers are eligible in the organization?

Will the eligible providers report for Medicare or Medicaid?

Who is responsible to enroll each provider with CMS?

Does an analysis of potential eligible providers need to be assessed to make the decision of MU reporting?

Does an analysis need to be done, and what patient population and/or diagnoses are seen by eligible providers to select the appropriate Clinical Quality Measures?

Will eligible providers have a choice on whether to participate in MU reporting or will it be decided by the organization?

Will each site, specialty, or provider select the measures (MENU and Clinical Quality Measures selections) or will it be directed from the organization?

Will there be a team dedicated for Meaningful Use?

Who will track the user’s behavior to ensure the necessary information is obtained?

These basic questions will allow the core Upgrade/Meaningful Use team to be prepared for configuration, workflow re-design, testing, and end user training. Each item can have a direct affect on one of the aspects of the upgrade/MU project. For example, if all eligible providers will be allowed to decide which measures they will select for reporting then the configuration team will need to configure to all CORE, MENU, and all 44 Clinical Quality Measures. In addition, if each provider selects their own measures ideally the training would be tailored around the measures for that eligible provider. Training all providers on all 44 Clinical Quality Measures or all 10 MENU items that may not pertain to that provider will not increase retention of the information and workflow change and likely decrease the MU reporting success. Another example, from the above proposed questions is Medicaid provides a greater financial return if the measures are met however what if no one meets the necessary 30% of patients? Does it make sense as an organization to increase an eligible provider’s percentage of Medicaid patients to capture the higher value and if so who makes this decision and how does the front office staff know to direct more new patients of a certain insurance to a certain provider?

Step 3- Workflow Redesign for Meaningful Use

Once the system is configured and reviewed by the implementation consultant during the upgrade process, the workflows will need to be re-designed to meet the Meaningful Use Measures to guarantee success! A workflow is not just the use of the application but also the process in place for monitoring the Meaningful Use within the organization. At this point, the system has been configured by the organization configuration team (system analyst) based on Steps 1 and 2. However, unless the users actually change behavior Meaningful Use will not count. Here are some examples below that will need to be considered based primarily on the CORE, MENU and Clinical Quality Measures.

CORE EXAMPLE: Suppose that currently the organization doesn’t allow clinical staff to enter and/or update problems or medications on patients, however the providers have not been keeping these lists up to date. Will the organization allow the clinical staff to begin to perform these tasks? Does configuration need to change to allow for retrospective/prospective authorization? Does enable verification of problems need to be added? Do clinical staff need to be trained how to do this item?

Remember there are many new alerts for Meaningful Use however everything doesn’t have an alert and likewise an end user can ignore an alert.

MENU EXAMPLE: Providing a Summary of Care Record to the patient and Patient Education. First, who will be responsible for providing the Summary of Care Record- clinical staff or providers? Will the Clinical Summary provided by Allscripts be used or will it print out from the v10 or v11 note? If the patient is a portal patient and you don’t want to provide a Clinical Summary or a non-portal patient how will the provider state if no Clinical Summary is to be provided? What/Who/How is the workflow to be defined, tested, and trained? Regarding Patient Education, will there be a standard developed if not already implemented such as every new medication prescribed by the provider the patient will receive the Drug Ed for that medication? How will the patient instructions be populated and printed?

Clinical Quality Measure EXAMPLE: Adult Weight Screening and Follow Up- many sites may already obtain the patient weight today and this may appear as an easy Clinical Quality Measure to capture. However, there are a couple of items to consider, by adding a free text box for comments to document if a patient denied obtaining their weight and if used would count for Meaningful Use. Is this configured already and/or do end users know to enter this information to count for Meaningful Use? In addition, to meet this measure the BMI of the patient needs to be evaluated and based on the patient’s age and BMI an additional workflow must be completed. Part of that measure states if the BMI is greater than 25kg/m2 a follow up plan must be in place. What will that plan be if not already used by an organization/site/provider? Will there be a dietary consultation or a BMI Management Follow Up Order? Will the end user be able to select from any of the potential recordable actions: Dietary consult with the appropriate SNOMED or the BMI Management Follow Up order with the appropriate CPT code? Will the clinical staff perform this action at the time the vital is taken or will the provider be responsible for adding this item on the patient.

These are some examples of Meaningful Use and all the decisions, configurations, and workflow changes that could be affected. This article is not all inclusive, rather, it is intended to begin the process for the team to meet the Meaningful Use objectives. Please feel free to contact Cary Bresloff, Cary.Bresloff@GalenHealthcare.com, for further questions, guidance, or consultation on Meaningful Use and the impact to an organization.